Title XXV Subcommittee Reviews New Payment System

By Tom Lacock
Wyoming Medical Society

CHEYENNE – The Wyoming Legislature’s Joint Subcommittee to Review Title XXV Issues has begun the process of payment reform for Title XXV payments to The State’s Community Mental Health Providers.

The committee met Monday in Cheyenne and moved to recommend a bill to the Legislature’s Joint Labor, Health, and Social Services Committee which would institute the Phase I of a new payment system which the Department of Health believes would help it collect more data, while Phase II would help to incentivize efforts to find those in the Title XXV system jobs, and housing.

The committee voted 7-4 to advance the bill with Committee Co-Chair Tony Ross (R-Cheyenne); Senator Jeff Wasserburger (R-Gillette); Bob Nicholas (R-Cheyenne); Sam Krone (R-Cody); Tom Forslund; Lou Hochheiser all voted yes.

Voting no were Sen. Leland Christensen (R-Teton County); Ray Peterson (R-Cowley); Co-Chair Rep. Mary Throne (D-Cheyenne); and Rep. Eric Barlow (R-Campbell County). Peterson repeated his concern that smaller provider in a more rural area would not have access to some of the wrap-around services nor the money that comes with them.

“I don’t know if the bill is the silver bullet, but I think this bill would have a long ways to go before it is implemented,” Ross said. “It may die in Labor committee but I don’t want to walk away from this committee with nothing in their hands. If we dangle this bill out there, people might work together and get it done. If we don’t have it out there, we have nothing.

“In my opinion we ought to do something as a committee to justify the time we have spent,” he concluded.

There was agreement in the room that the new payment model isn’t perfect, but many of the stakeholders are offering their willingness to work on the issue. WAMHSAC says they would like to support the model but there are too many questions unanswered.

Stefan Johansen of the Wyoming Department of Health said the hope is that Community Mental Health Centers and other providers begin to offer a holistic approach to treatment by incentivizing performances such as helping someone find housing after treatment (45 percent of IH’s are homeless or live alone) or a job. Not surprisingly, just 1.4 percent of IH patients have private insurance with 65 percent having no insurance at all and 19.6 percent having just Medicare.

The bigger hope of WDH is simply to collect better data on the issues associated with treatment of the Title XXV population. They consider Phase I to be the data collection piece by using the new payment/data collection effort while helping providers to avoid system shock and Phase II will be more innovative.

New Chart B Claims System Update
The Wyoming Department of Health has launched its Chart B Claims Services Update for Title XXV payments on Aug. 1 in an attempt to streamline the data collection and automate payment. Thus far facilities who are having difficulty with the system as illustrated by the fact 55 of the 58 claims submitted to the WDH through the system were returned for missing information such as incorrect dates, or a missing certificate (that there is no other way for a client to pay).

This is a similar system to what the Department hopes to move Community Mental Health Centers to if Payment Reform is approved.

Utilization Review by Xerox and Optum
Optum and Xerox have also been doing vendor-based utilization review at the State Hospital and determined the average length of stay is 184 days for all patients, which the WDH says is skewed by a few long-term patients. The short-term ALOS (less than 180 days) is 73 days. this is where 80 percent of the facility’s clients fall. WDH’s Stefan Johansen said 73 days as ALOS is quite high versus the averages that they see nationwide.

The average long-term client is at WSH for 548 days. There are 20 percent of the patients who fall into this category.

One-third of the patients at WSH had secondary diagnosis of substance abuse disorder. Top three diagnoses are:  psychotic spectrum disorder (40 percent); depressive disorder (34 percent), and bipolar disorder (23 percent).

10,142 patient days could not meet medical necessity (level of care 6 on the LOCUS score). This had to do with getting patients wraparound services, and placements out of Evanston, etc.

Award of Outpatient Treatment Grant

The Wyoming Department of Health applied for and has received a grant through Substance Abuse and Mental Health Service Administration (SAMSA). It is offered to states who allow for outpatient commitments. This grant helps states develop those outpatient commitment programs.

WDH will receive $3.7 million over a four year period. Central Wyoming Counseling Service aided in the grant writing and will take $533,000 of the $700,000 that the state receives in year one. They will work to develop levels of care in Natrona County for those entering the Title XXV process. Among their goals is to develop crisis beds, and employment services, along with case management.

Another $60,000 will pay for a consultant to develop procedures and training for outpatient commitments. Another $50,000 will go towards data reporting processes, $56,000 for administration.

This grant can be used for many things, but cannot be used for construction purposes.

Title VII Statute Changes
Presented by Cari Cuffney of WDH. The good news around Title VII is that wait times for Title VII evaluations are down from a month ago but that number is expected to rise as the Wyoming system has lost two of its evaluators. Average wait time for inpatient evaluation is current running at 67 days. Title VII is asking for this committee some policy changes such as capping the number of State Hospital evaluations, limit the types of evaluations conducted at the State Hospital, set a fee schedule for evaluations, or processing court orders such as closing cases in which the defendant has failed to cooperate or appear for scheduled interview.

Wyoming Title 14 (youth) provides for specific financial and jail time penalties. In Colorado failing to cooperate bars the defendant from calling expert witnesses to testify on mental health status; Michigan and Minnesota, a failure to appear results in inpatient order or revocation or bond. Colorado and Oregon also charge for the cost of an evaluation unless indigent, in which case the state is responsible for the first one and the court pays the second.

WDH notes
Forslund noted that at this point a lack of support of medication after release means many end up back in the system. He would like to see that improved.

Forslund pointed out that there is no one in WDH whose job it is to oversee the Title XXV program. If he continues to have his current budget he will re-purpose someone to oversee the program full-time.

WDH and the committee both agreed that because it is unlikely that the Wyoming Legislature will approve Medicaid Expansion, it may make sense to consider an adult mental health waiver which would take the population with a mental health diagnosis and an income of 150 percent and make it Medicaid-eligible.

Other Bills
Nicholas suggested he has asked LSO to draft a bill, but didn’t think it would be completed in time for discussion by the Labor, Health and Social Service Committee which would divide payment of Title XXV dollars per capita by county. He suggested it may be brought to the legislature outside of the committee.

“If we can’t get control over inputs in Casper which is using most of the dollars, we may need a balancing mechanism and we may need to to do that statutorily,” Nicholas said.

Mary Throne said Bern Haggerty, Laramie County Attorney emailed her suggesting one way to reduce the diagnosis of inability to care for self (16 percent of IH’s) is if an adult protection order allowed for a longer hold than 72 hours. He suggested 30 or 60 days. The committee voted on a proposal to move forward a 60-day hold if the court sees fit. Click here to see the bill.

Another bill would have providers check for all sources of payments including VA, IHS, Health and Human Services, and any other federal agency that could be responsible for treatment.

New Information on State Facilities
Joint Subcommittee on Title XXV Issues member Nicholas was tasked with offering an update on the work by the State Facilities Task Force. Nicholas said the Task Force has visited other state facilities in Montana and Oregon recently to see other state hospitals and is incorporating ideas into future renovations to the Wyoming State Hospital in Evanston, as well as the Life Resource Center in Lander.

Currently, Nicholas said the State Facilities Task Force is meeting monthly in both Evanston and Lander. By the end of March the Task Force should have a budget and drawings for work to be done at the State Hospital and about 90 percent of the same information for the Lander facility.

This far contractors are suggesting preliminary estimates for the renovations are around $10 million under what they should be due to changes in items such as furniture. LSO staff suggests the total scope of work will be $145 million and the Legislature has set aside around $70 million.

The architects are being asked to work with two plans going forward. The first is to proceed as though all cash will be available. If the state funds are not available, the work on the Life Resource Center will be placed on hold and there will be some changes needed in the design of the State Hospital.

Gatekeeper Update
Wyoming Department of Health Director Tom Forslund said he will meet with Judge James, and other stakeholders in Sweetwater County on Thursday. The hope is they will be able to start working together on the Gatekeeper process. The process is moving forward in Casper, though Forslund’s comments made it sound like he was frustrated it was taking as long as it has.

Does Title XXV Committee Continue?
Technically the Title XXV will sunset at the end of this year, but the committee does have the ability to suggest it’s continuation to the Legislature’s Management Council. Mary Throne said she believes this committee should continue, but believes a more holistic approach is necessary. She said the committee has identified the need for more wrap-around services, which is beyond pure Title XXV. She believes a broader mission would be helpful.